Financing of health care in four Caribbean territories: a comparison with reforms in Europe

Health system dynamics analysis of eyecare services in Trinidad and Tobago and progress towards Vision 2020 Goals

Avoidable blindness is an important global public health concern. This study aimed to assess Trinidad and Tobago's progress towards achieving the Pan American Health Organization, 'Strategic Framework for Vision 2020: The Right to Sight-Caribbean Region,' indicators through comprehensive review of the eyecare system, in order to facilitate health system priority setting. We administered structured surveys to six stakeholder groups, including eyecare providers, patients and older adult participants in the National Eye Survey of Trinidad and Tobago. We reviewed reports, registers and policy documents, and used a health system dynamics framework to synthesize data. In 2014, the population of 1.3 million were served by a pluralistic eyecare system, which had achieved 14 out of 27 Strategic Framework indicators. The Government provided free primary, secondary and emergency eyecare services, through 108 health centres and 5 hospitals (0.26 ophthalmologists and 1.32 ophthalmologists-in-training per 50 000 population). Private sector optometrists (4.37 per 50 000 population), and ophthalmologists (0.93 per 50 000 population) provided 80% of all eyecare. Only 19.3% of the adult population had private health insurance, revealing significant out-of-pocket expenditure. We identified potential weaknesses in the eyecare system where investment might reduce avoidable blindness. These included a need for more ophthalmic equipment and maintenance in the public sector, national screening programmes for diabetic retinopathy, retinopathy of prematurity and neonatal eye defects, and pathways to ensure timely and equitable access to subspecialized surgery. Eyecare for older adults was responsible for an estimated 9.5% (US$22.6 million) of annual health expenditure. This study used the health system dynamics framework and new data to identify priorities for eyecare system strengthening. We recommend this approach for exploring potential health system barriers to addressing avoidable blindness, and other important public health problems.

Toward Explicit Prioritization for the Caribbean: An EQ-5D Value Set for Trinidad and Tobago

BACKGROUND

Resource allocation decision making in the Caribbean can be greatly enhanced by the introduction of cost per quality-adjusted life-year (QALY) analysis on the basis of local preferences. In the valuation literature there have been recommendations for the elicitation methods of the EuroQol five-dimensional questionnaire (EQ-5D) that combine discrete-choice experiment (DCE) for bulk valuation with a time trade-off component for rescaling.

OBJECTIVES

To create a three-level EQ-5D value set for Trinidad and Tobago using an elicitation method that takes into account the local constraints, and that can be easily deployed in other Caribbean islands.

METHODS

A D-efficient DCE was completed by a representative sample of 307 adults. A time trade-off procedure was used to obtain values for rescaling the DCE model on a scale anchored at 0 (dead) and 1 (full health).

RESULTS

A mixed logit analysis of the DCE data produced an internally valid model that is similar to the results obtained in earlier pilot studies.

CONCLUSIONS

This EQ-5D value set allows cost per QALY analyses to be carried out on the basis of preferences from Trinidad and Tobago, and the approach to the DCE design can be taken for similar value sets to be created in the small, resource-constrained health systems of the Caribbean. Some guidelines for the initial application and introduction of cost per QALY analysis into the Trinidad and Tobago health system are also presented.

Primary care in Caribbean Small Island Developing States

Caribbean Small Island Developing States (SIDS) made good process on improving the health of their populations; but concerns exist when it comes to meeting changing health needs. Due to remoteness and limited resources it is difficult to respond to high rates of non-communicable diseases (NCDs). Furthermore, little is known about how primary care (PC) is organised and how this responds to current health issues. This study focused on gaining insights in the organisation of PC of Caribbean SIDS based on currently available literature. This literature review was an explorative multiple case study, where structure of PC and health status of 16 Caribbean SIDS were reviewed using available scientific and grey literature between the years 1997 and 2014. Thirty documents were used to analyse 20 indicators for the dimensions “Structure of Primary Care” and “Health Status”. Results were mapped in order to identify if there is a possible relation between structures of PC to the health of the populations. When reviewing the structure of PC, the majority of information was available for “Economic conditions of PC” (78%) and the least information was available for “Governance of PC” (40%). With regards to health status, all islands show improvements on “Life expectancy at birth” since 2007. In contrast, on average, the mortality due to NCDs did not improve. Saint Lucia performs best on “Structure of PC”. The British Virgin Islands have the best health status. When both dimensions were analysed, Saint Lucia performs best. There is still little known on the responsiveness of PC of Caribbean SIDS to NCDs. There is a need for elaborate research on: (1) If and how the functioning of these health systems relate to the health status; (2) What islands can learn from an analysis over time and what they can learn from cross-island analysis; and (3) Filling the gaps of knowledge which currently exist within this field of research.

Predicting factors associated with costs of diabetic patients in Taiwan

This study examined healthcare costs for medication-using diabetic patients in Taiwan and predicted which factors were associated with costs. We analyzed claims data from the National Health Insurance (NHI) program in Taiwan from 1998 to 1999. The approach included estimates of costs attributable to diabetes, diabetes-related complications, comorbidity incurred by diabetic patients. A multiple regression model was used to assess the contribution of patients' characteristics in 1998 on outpatient, inpatient, and total costs in 1998 and 1999. The prevalence of medication-using patients with diabetes was 2.6% in 1998 and 2.8% in 1999. Costs of healthcare were 13.3% of total costs of NHI in 1998 versus 13.0% in 1999. Health services delivered near the end of life consumed large portions of medical dollars. The three most prevalent clinical associations of diabetes were congestive heart failure, neuropathy, and ischemic heart disease. Adjusted for demographic and clinical characteristics in 1998, this model could explain 8.0, 9.3, and 12.5%, respectively, of the cost variation in outpatient, inpatient, and total costs in 1999.

Diabetes-related inequalities in health status and financial barriers to health care access in a population-based study

AIMS

We evaluated the relationship between diabetes, health status, household income and expenditure on health care in the general population in Trinidad.

METHODS

Multistage sampling of 300 households was used to select a sample of 548 adults aged > or = 25 years. There were 64 (12%) who reported a diagnosis of diabetes. Comparison was made with 128 non-diabetic controls who were frequency matched for age and sex.

RESULTS

Subjects with diabetes had lower income levels than non-diabetic controls [income < or = US dollars 533 per month for 66% diabetes cases and 48% controls, test for trend P = 0.007]. Compared with controls, subjects with diabetes were less likely to have good or very good self-rated health (diabetes 32%, controls 67%; P < 0.001), and more frequently reported long-standing illness, limitation of activities, visual impairment, or self-reported history of high blood pressure, angina or heart attack. Subjects with diabetes (11%) were less likely than controls (30%) to have private health insurance (P = 0.005). Diabetic subjects (35%) were more likely than controls (16%) to have incurred expenditure on doctors' services in the last 4 weeks (P = 0.021).

CONCLUSIONS

Diabetes is associated with worse health status and more frequent expenditure on medical services but greater financial barriers to access in terms of low income and lack of health insurance. Policies for diabetes should specifically address the problem of income-related variations in risk of diabetes, health care needs and barriers to uptake of preventive and treatment services, otherwise inequalities in health from this condition may increase.